College Code:

For college use only

Course Admitted to: Admission date: / /

Division: Roll No:

Form No:

Kindly read important notes before filling-in form: 1. Use black ink to fill in the form and Do NOT overwrite. 2. Fill in all fields in CAPITAL letters only. 3. Strike-off whichever is NOT applicable. E.g. If you are a Male :-> Gender: Male / Female

Please paste a passport size (35 mm X 45 mm) Photograph here, Do NOT staple. Photo should not exceed the borders.

Course applied for (e.g.BA/BCom/BE): Course Part or Semester applied for (e.g. 1/2/3/4): Student should sign strictly inside this box only with black ink

Applying for Concession EBC / SC / ST / NT / OBC / SBC / PTC / STC / Freedom Fighter / Ex Service Man : Admitted against which Category : Open / Reserved If Reserved, Specify:

1. Personal Information Section

Last Name First Name Middle Name

Name of the Student:

(In case of changed name, write current name) Name of the Student: (In local language)

Name of the Student as printed on std. 10 Passing Certificate Fathers/Husbands Name: Mother's Name: Previous name of the Student:
(In case of changed name)

Reason for name change: Willingly / After Marriage Date of Birth (DD/MM/YYYY): / / Place of Birth: Religion:

Marital Status: Unmarried / Married/Divorced/ Widowed/Desserted Gender: Male / Female Blood Group (with Rh): Citizen of (country name):

Students location Category: Rural/ Urban/ Tribal

Address for Correspondence State: District: Tehsil: City/Town/Village:

Address (House no, street/area/suburb etc.) PIN Code: Permanent Address [Write only if different than Address for Correspondence] State: District: Address (House no, street/area/suburb etc.) PIN Code: Contact Details Phone # 1: STD Code: Mobile number: Domicile of State: Caste: Phone No: Email ID: Phone # 2: STD Code: Phone No: Tehsil: City/Town/Village:

2. Legal Reservation Information Section

Category: Open / Reserved If Reserved: SC / ST / DT(A) / NT(B) / NT(C) / NT(D) / OBC / SBC Sub-Caste: If Physically Challenged: Visually Impaired / Speech and/or Hearing Impaired / Orthopedic Disorder or Mentally Retarded Reservation Information Section [Check () whichever is applicable, write name of supporting document attached, in section 6.] Member of Project Affected Family Member of Earthquake Affected Family Member of Flood / Famine Affected Family Resident of Tribal Area Kashmir Migrant

3. Social

Ex-Serviceman/Ward of Ex-Serviceman Active-Serviceman/Ward of Active-Serviceman Freedom Fighter/Ward of Freedom Fighter Ward of Primary Teacher Ward of Secondary Teacher Deserted/Divorced/Widowed Women

4. Guardian Information Section

Occupation of the Guardian: Service / Business / Profession / Farmer / Laborer / Retired Relationship of guardian with applicant: Annual Income of the Guardian (Rs.): (last financial year) Phone No.:

Please Turn Over

Form No. :

5. Educational Details Section

Name of Examination
th *

[Write YES in last column, against the qualifying examination, on basis of which you are seeking admission to the said course write NO in front of th other examinations] Please Note: 10 Details are mandatory in any case Last College Attended: Year: Roll No.:
Name of Board /University Name of School/College Date of Passing (DD/MM/Y YYY) Examination Seat No. (Last) Degree / Passing Certificate No. Grade / Total Marks Obtained Out of Qualifying Examination? (YES/NO)

Std 10 th Std 12

6. Selected/Opted Papers Section [Write paper codes or Paper Name only, in the boxes] Year/ Semester: 1/3/5/7 Semester: 2/4/6/8 (If decided in First Semester only) 1. 1. 2. 2. 3. 3. 4. 4. 5. 5. 6. 6. 7. 7. 8. 8. 7. Attached Documents and Certificates Section
Sr. No. 1 2 3 4 5 6 7 8 9 10 Name of Document/Certificate th * Passing Certificate of Std 10 Passing Certificate of Std 12 / Statement of Marks of Std 12 Leaving Certificate Certificate of Caste with Category Non Creamy Layer Certificate Affidavit for changed name/ Marriage Certificate / Govt. Gazette Domicile Certificate Certificate for Physically Challenged
th th

Original / Attested True Copy Attested True Copy (Mandatory) Attested True Copy Original Attested True Copy Attested True Copy Original Attested True Copy Attested True Copy

Attached (Yes/No)

8. Other Information Section

Mother Tongue: Would you like to apply for Hostel: Yes / No Hobbies, Proficiency and Other Interests: Games and Sports participation: Level (e.g. college/state/national/international etc.): Personal Identification Marks: 1. 2. Employment Status: Employed / Unemployed Do you wish to join NCC / NSS : Yes / No

9. Declaration by Student
I hereby declare that, I have read the rules related to admission and the information filled in by me in this form is accurate and true to the best of my knowledge. I will be responsible for any discrepancy, arising out of the form signed by me and I undertake that, in absence of any document the final admission will not be granted and/or admission will stand cancel. I am aware of the Maharashtra Prohibition of Ragging Act, 1999 and I state that I will abide by all the rules and regulations of the said Act.
Place: Date: Signature of the student:

10. Declaration by Guardian

I have permitted my son/daughter/ward to join your college. The information supplied by him/her is correct to the best of my knowledge. I have acquainted myself with the rules and fees, dues to my son/daughter/ward and to see that he/she observes.
Place: Date: Signature of the Guardian: Remarks / Particulars / Recommendations Signature and date

11. For College/Institute Use Only

Designation Admission Clerk Admission Committee Accountant/Cashier Registrar/Office Superintendent Principal/Director Cash Received: Rs. Receipt No.:

Note: Student MUST retain photocopy of completely filled in admission form (both pages) for future reference. Available information in this form will be required to activate his/her account on Digital University Portal.